UNITED INDIA INSURANCE COMPANY LIMITED

REGISTERED & HEAD OFFICE: 24, WHITES ROAD, CHENNAI-600014

(Special Conditions applicable to co-branded Indian Bank Arogya Raksha
Group Health Insurance Policy are furnished along with this document)

HEALTH INSURANCE POLICY GROUP

1 WHEREAS the insured designated in the Schedule hereto has by a

proposal and declaration dated as stated in the Schedule which shall be
the basis of this Contract and is deemed to be incorporated herein has
applied to UNITED INDIA INSURANCE COMPANY LTD. (hereinafter
called the COMPANY) for the insurance hereinafter set forth in respect
of Employees/Members (including their eligible family members)
named in the Schedule hereto (hereinafter called the INSURED
PERSON) and has paid premium as consideration for such insurance.

1.1 NOW THIS POLICY WITNESSES that subject to the terms, conditions,
exclusions and definitions contained herein or endorsed, or otherwise
expressed hereon the Company undertakes that if during the period
stated in the Schedule or during the continuance of this policy by
renewal any insured person shall contract any disease or suffer from
any illness (hereinafter called DISEASE) or sustain any bodily injury
through accident (hereinafter called INJURY) and if such disease or
injury shall require any such insured Person, upon the advice of a duly
qualified Physician/Medical Specialist / Medical practitioner
(hereinafter called MEDICAL PRACTITIONER) or of a duly qualified
Surgeon (hereinafter called SURGEON) to incur
hospitalization/domiciliary hospitalization expenses for
medical/surgical treatment at any Nursing Home/Hospital in India as
herein defined (hereinafter called HOSPITAL) as an inpatient, the
Company will pay through TPA to the Hospital / Nursing Home or
Insured the amount of such expenses as are reasonably and necessarily
incurred in respect thereof by or on behalf of such Insured Person but
not exceeding the Sum Insured in aggregate in any one period of
insurance stated in the schedule hereto.

1.2 In the event of any claim becoming admissible under this scheme, the
company will pay through TPA to the Hospital / Nursing Home or
insured person the amount of such expenses as would fall under
different heads mentioned below and as are reasonably and medically
 necessary incurred thereof by or on behalf of such insured person but
not exceeding the Sum Insured in aggregate mentioned in the schedule
hereto.

A. Room, Boarding and Nursing expenses as provided by the

Hospital/Nursing Home not exceeding 1% of the sum insured per
day or the actual amount whichever is less. This also includes
nursing care, RMO charges, IV Fluids/Blood transfusion/injection
administration charges and similar expenses.
B. Intensive Care Unit (ICU) expenses not exceeding 2% of the sum
insured per day or actual amount whichever is less.
C. Surgeon, Anesthetist, Medical Practitioner, Consultants,
Specialists Fees.
D. Anesthetic, Blood, Oxygen, Operation Theatre Charges, surgical
appliances, Medicines & Drugs, Dialysis, Chemotherapy,
Radiotherapy, Cost of Artificial Limbs, cost of prosthetic devices
implanted during surgical procedure like pacemaker, orthopedic
implants, infra cardiac valve replacements, vascular stents,
relevant laboratory/diagnostic tests, X-ray and such similar
expenses that are medically necessary.
E. Hospitalization expenses (excluding cost of organ) incurred on
donor in respect of organ transplant to the insured.

Note: 1. the amount payable less than 1.2 C & D above shall be at the
rate applicable to the entitled room category.
In case the Insured person opts for a room with rent higher than
the entitled category as in 1.2 A above, the charges payable under
1.2 C & D shall be limited to the charges applicable to the entitled
category. This will not be applicable in respect of medicines &
drugs and implants.
2. No payment shall be made under 1.2 C other than as part of
the Hospitalisation bill.
1.2.1 Expenses in respect of the following specified illnesses/surgeries will
be restricted as detailed below:
LIMITS per surgery RESTRICTED TO
Hospitalization Benefits
a. Cataract, Hernia, a. Actual expenses incurred or 25% of the sum
Hysterectomy insured whichever is less

b. Major surgeries* b. Actual expenses incurred or 70% of the

Sum Insured whichever is less
 * Major surgeries include Cardiac surgeries, Brain Tumor surgeries,
Pacemaker implantation for sick sinus syndrome, Cancer surgeries, Hip,
Knee, joint replacement surgery, Organ Transplant.
* The above limits specified are applicable per hospitalization / surgery.

1.3 Pre and Post Hospitalization expenses payable in respect of each

hospitalization shall be the actual expenses incurred subject to a
maximum of 10% of the Sum Insured.

1.4 In addition to the above, the following would apply to claims arising out of
persons aged more than 60 years

TO BE SETTLED WITH A CO-PAY ON 80:20 BASIS.

EXPENSES ON MAJOR ILLNESSES
The co-pay of 20% will be applicable on the
CHARGED AS A TOTAL PACKAGE
admissible claim amount.

2. DEFINITIONS:
2.1 ACCIDENT:
An accident is a sudden, unforeseen and involuntary event caused by
external, visible and violent means.

2.2
A. Acute condition Acute condition is a disease, illness or injury that is
likely to respond quickly to treatment which aims to return the
person to his or her state of health immediately before suffering the
disease/illness/injury which leads to full recovery.

B. Chronic condition A chronic condition is defined as a disease, illness,

or injury that has one or more of the following characteristics
i. it needs ongoing or long-term monitoring through
consultations, examinations, check-ups and/or tests
ii. it needs ongoing or long-term control or relief of symptoms
iii. it requires your rehabilitation or for you to be specially
trained to cope with it
iv. it continues indefinitely
v. it comes back or is likely to come back.

2.3 ALTERNATIVE TREATMENTS:

Alternative Treatments are forms of treatment other than treatment
Allopathy or modern medicine and includes Ayurveda, Unani, Siddha
and Homeopathy in the Indian Context.
2.4 ANY ONE ILLNESS:
Any one illness will be deemed to mean continuous period of illness and
it includes relapse within 45 days from the date of last consultation with
the Hospital / Nursing Home where treatment has been taken.
Occurrence of the same illness after a lapse of 45 days as stated above
will be considered as fresh illness for the purpose of this policy.

2.5 CASHLESS FACILITY:

Cashless facility means a facility extended by the insurer to the insured
where the payments, of the cost of treatment undergone by the insured
in accordance with the policy terms and conditions, or directly made to
the network provider by the insurer to the extent preauthorization
approved.

2.6 CONGENITAL ANOMALY:

Congenital Anomaly refers to a condition(s) which is present since birth,
and which is abnormal with reference to form, structure or position.
a. Internal Congenital Anomaly which is not in the visible and accessible
parts of the body
b. External Congenital Anomaly which is in the visible and accessible
parts of the body

2.7 CONDITION PRECEDENT:

Condition Precedent shall mean a policy term or condition upon which
the Insurers liability under the policy is conditional upon.

2.8 CONTRIBUTION:
Contribution is essentially the right of an insurer to call upon other
insurers liable to the same insured, to share the cost of an indemnity
claim on a rateable proportion.

2.9 DAYCARE CENTRE:

A day care centre means any institution established for day care
treatment of illness and/ or injuries or a medical setup within a hospital
and which has been registered with the local authorities, wherever
applicable, and is under the supervision of a registered and qualified
medical practitioner AND must comply with all minimum criteria as
under;-
- has qualified nursing staff under its employment
- has all qualified medical practitioner(s) in charge
- has a fully equipped operation theatre of its own where surgical
procedures are carried out.
 - maintains daily records of patients and will make these accessible to
the insurance companies authorized personnel.

2.10 DAY CARE TREATMENT:

Day care Treatment refers to medical treatment and or surgical
procedure which is,
i. undertaken under general or local anesthesia in a hospital/day care
centre in less than 24 hours because of technological advancement,
ii. This would have otherwise required a hospitalisation of more than 24
hours.
Treatment normally taken on an outpatient basis is not included in the
scope of this definition.

2.11 DOMICILIARY HOSPITALIZATION:

Domiciliary Hospitalization means medical treatment for an
illness/disease/injury which in the normal course would require care and
treatment at a hospital but is actually taken while confined at home
under any of the following circumstances:
a) The condition of the patient is such that he/she is not in a condition
to be removed to a hospital or
b) The patient takes treatment at home on account of non-availability of
room in a hospital.

2.12 GRACE PERIOD:

Grace Period means the specified period of time immediately following
the premium due date during which a payment can be made to renew or
continue a policy in force without loss of continuity benefits such as
waiting periods and coverage of pre-existing diseases. Coverage is not
available for the period for which no premium is received.

2.13 HOSPITAL / NURSING HOME:

A Hospital means any institution established for in-patient care and day
care treatment of illness and/or injuries and which has been registered
as a Hospital with the local authorities under the Clinical establishments
(Registration and Regulation) Act, 2010 or under the enactments
specified under the Schedule of Section 56(1) of the said Act OR
complies with all minimum criteria as under
- Has qualified nursing staff under its employment round the clock.
- Has at least 10 in-patient beds in towns having a population of less
than 10 lacs and at least 15 in-patient beds in all other places;
- Has qualified medical practitioner(s) in charge round the clock;
 - Has a fully equipped Operation Theatre of its own where surgical
procedures are carried out;
- Maintains daily records of patients and makes these accessible to
the insurance companys authorized personnel.

The term 'Hospital/Nursing Home' shall not include an establishment

which is a place of rest, a place for the aged, a place for drug-addicts or
place for alcoholics, a hotel or a similar place.

2.14 HOSPITALIZATION:
Hospitalization means admission in a Hospital/Nursing Home for a
minimum period of 24 consecutive hours of inpatient care except for
specified procedures/treatments, where such admission could be for a
period of less than 24 consecutive hours

2.15 ID CARD:
ID card means the identity card issued to the insured person by the TPA
to avail cashless facility in network hospitals.

2.16 ILLNESS:
Illness means a sickness or a disease or pathological condition leading to
the impairment of normal physiological function which manifests itself
during the policy period and requires medical treatment.

2.17 INJURY:
Injury means accidental physical bodily harm excluding illness or disease
solely and directly caused by external, violent and visible and evident
means which is verified and certified by a medical practitioner.

2.18 IN PATIENT CARE:

In Patient Care means treatment for which the insured person has to
stay in a hospital for more than 24 hours for a covered event.

2.19 INTENSIVE CARE UNIT:

Intensive Care Unit means an identifies section, ward or wing of a
Hospital which is under the constant supervision of a dedicated medical
practitioner(s) and which is specially equipped for the continuous
monitoring and treatment of patients who are in a critical condition, or
require life support facilities and where the level of care and supervision
is considerably more sophisticated and intensive than in the ordinary
and other wards.
 2.20 MATERNITY EXPENSES:
Maternity expenses/treatment shall include:
a) Medical treatment expenses traceable to childbirth (including
complicated deliveries and caesarean sections incurred during
hospitalization).
b) Expenses towards lawful medical termination of pregnancy during the
policy period.

2.21 MEDICAL ADVICE:

Any consultation or advice from a medical practitioner/ doctor including
issuing of any prescription or repeat prescription.

2.22 MEDICAL EXPENSES:

Medical Expenses means those expenses that an insured person has
necessarily and actually incurred for medical treatment on account of
illness or accident on the advice of a medical practitioner, as long as
these are no more than would have been payable if the insured person
had not been insured and no more than other hospitals or doctors in the
same locality would have charged for the same medical treatment.

2.23 MEDICALLY NECESSARY:

Medically necessary treatment is defined as any treatment, test,
medication or stay in hospital or part of a stay in a hospital which

- is required for the medical management of the illness or injury

suffered b y the insured;
- must not exceed the level of care necessary to provide safe, adequate
and appropriate medical care in scope, duration or intensity;
- must have been prescribed by a medical practitioner;
- must conform to the professional standards widely accepted in
international medical practice or by the medical community in India.

2.24 MEDICAL PRACTITIONER:

Medical Practitioner is a person who holds a valid registration from the
Medical Council of any State or Medical Council of India or Council for
Indian Medicine or the homeopathy set up by the Government of India or
a State Government & is thereby entitled to practice medicine within its
jurisdiction; & is acting within the scope and jurisdiction of his license. The
term medical practitioner would include physician, specialist & surgeon.
(The Registered practitioner should not be the insured or close family
members such as parents, in-laws, spouse and children.)
2.25 NETWORK PROVIDER:
Network Provider means hospitals or health care providers enlisted by an
insurer or by a TPA and insurer together to provide medical services to an
insured on payment by a cashless facility.

The list of network hospitals is maintained by and available with the TPA
and the same is subject to amendment from time to time.

Preferred Provider Network means a network of hospitals which have

agreed to a cashless packaged pricing for certain procedures for the
insured person. The list is available with the company/TPA and subject to
amendment from time to time. Reimbursement of expenses incurred in
PPN for the procedures (as listed under PPN package) shall be subject to
the rates applicable to PPN package pricing.

2.26 NEW BORN BABY:

A new born baby means baby born during the Policy Period aged between
one day and 90 days, both days inclusive.

2.27 NON NETWORK:

Any hospital, day care centre or other provider that is not a part of the
network.

2.28 NOTIFICATION OF CLAIM

Notification of claim is the process of notifying a claim to the insurer or
TPA by specifying the timelines as well as the address/telephone number
to which it should be notified.

2.29 OPD TREATMENT:

OPD Treatment is one in which the insured visits a clinic/hospital or
associated facility like a consultation room for diagnosis and treatment
based on the advice of medical a practitioner. The insured is not admitted
as a day care or in-patient.

2.30 PRE-EXISTING DISEASE:

Pre Existing Disease is any condition, ailment or injury or related
condition(s) for which you ad signs or symptoms, and/or were diagnosed,
and/or received medical advice/treatment, within 48 months prior to the
first policy issued by the insurer.
2.31 PORTABILITY:
Portability means transfer by an individual health insurance policy holder
(including family cover) of the credit gained for pre-existing conditions and
time-bound exclusions if he/she chooses to switch from one insurer to
another.

2.32 PRE HOSPITALISATION MEDICAL EXPENSES:

Medical expenses incurred immediately 30 days before the insured person
is hospitalized will be considered as part of a claim as mentioned under
Item 1.2 above provided that;

i. such medical expenses are incurred for the same condition for which
insured persons hospitalization was required and

ii. Inpatient hospitalization claim for such hospitalization is admissible by

the insurance company.

2.33 POST HOSPITALISATION MEDICAL EXPENSES:

Relevant medical expenses incurred immediately 60 days after the Insured
person is discharged from the hospital provided that:

a. Such Medical expenses are incurred for the same condition for which the
Insured Persons Hospitalization was required; and

b. The In-patient Hospitalization claim for such Hospitalization is admissible

by the Insurance Company.

2.34 QUALIFIED NURSE:

Qualified Nurse is a person who holds a valid registration from the Nursing
Council of India or the Nursing Council of any state in India and/or who is
employed on recommendation of the attending medical practitioner.

2.35 REASONABLE AND CUSTOMARY CHARGES:

Reasonable Charges means the charges for services or supplies, which are
the standard charges for the specific provider and consistent with the
prevailing charges in the geographical area for identical or similar services,
taking into account the nature of the illness/injury involved.

2.36 RENEWAL:
Renewal defines the terms on which the contract of insurance can be
renewed on mutual consent with a provision of grace period for treating
the renewal continuous for the purpose of all waiting periods.
2.37 ROOM RENT:

Room Rent shall mean the amount charged by the hospital for the
occupancy of a bed on per day (24 hours) basis and shall include associated
medical expenses.

2.38 SUBROGATION:

Subrogation shall mean the right of the insurer to assume the rights of the
insured person to recover expenses paid out under the policy that may be
recovered from any other source.

2.39 SURGERY:
Surgery or surgical procedure means manual and/or operative
procedure(s) required for treatment of an illness or injury, correction of
deformities and defects, diagnosis and cure of diseases, relief of suffering
or prolongation of life, performed in a hospital or day care centre by a
medical practitioner.

2.40 THIRD PARTY ADMINISTRATOR

TPA means a Third Party Administrator who holds a valid License from
Insurance Regulatory and Development Authority to act as a THIRD PARTY
ADMINISTRATOR and is engaged by the Company for the provision of
health services as specified in the agreement between the Company and
TPA.

2.41 UNPROVEN/EXPERIMENTAL TREATMENT:

Unproven/Experimental treatment is treatment, including drug

Experimental therapy, which is not based on established medical practice
in India.

3. COVERAGES:

3.1 Expenses on Hospitalization for minimum period of 24 hours are admissible.

However, this time limit is not applied to specific treatments, such as
 1 Adenoidectomy 19 FESS
2 Appendectomy 20 Haemo dialysis
3 Ascitic/Pleural tapping 21 Fissurectomy / Fistulectomy
4 Auroplasty 22 Mastoidectomy
5 Coronary angiography 23 Hydrocele
6 Coronary angioplasty 24 Hysterectomy
7 Dental surgery 25 Inguinal/ventral/umbilical/femoral
hernia
8 D&C 26 Parenteral chemotherapy
9 Endoscopies 27 Polypectomy
10 Excision of Cyst/granuloma / 28
Septoplasty
lump
11 Eye surgery 29 Piles/ fistula
12 Fracture/dislocation excluding 30 Prostrate
hairline fracture
13 Radiotherapy 31 Sinusitis
14 Lithotripsy 32 Tonsillectomy
15 Incision and drainage of abcess 33 Liver aspiration
16 Colonoscopy 34 Sclerotherapy
17 Varicocelectomy 35 Varicose Vein Ligation
18 Wound suturing

Or any other surgeries/procedures agreed by the TPA/Company which

require less than 24 hours hospitalization and for which prior approval
from TPA/Company is mandatory. This condition will also not apply in case
of stay in hospital of less than 24 hours provided -

a) The treatment is such that it necessitates hospitalization and the

procedure involves specialized infrastructural facilities available in
hospitals.
b) Due to technological advances hospitalization is required for less than 24
hours only.
c) They are carried out in Day Care Centre networked by TPAs where
requirement of minimum number of beds is overlooked but having (i)
fully equipped Operation Theatre, (ii) fully qualified Day Care Staff (c)
fully qualified Surgeons/Post-Operative attending Doctors.

Note 1: Procedures/treatments usually done in outpatient department are

not payable under the policy even if converted as an in-patient in the
hospital for more than 24 hours or carried out in Day Care Centers.
 Note 2: When treatment such as dialysis, Chemotherapy, Radiotherapy. etc
is taken in the hospital / nursing home/Day-care centre and the insured is
discharged on the same day the treatment will be considered to be taken
under hospitalization benefit section

3.2 Domiciliary Hospitalisation means medical treatment for a period exceeding

three days for such an illness/disease/injury which in the normal course
would require care and treatment at a hospital but is actually taken while
confined at home under any of the following circumstances:

a. The condition of the patient is such that he/she is not in a condition to

be removed to a hospital or
b. The patient takes treatment at home on account of non-availability of
room in a hospital.
Subject however that domiciliary hospitalisation benefits shall not cover:

i) Expenses incurred for pre and post hospital treatment and

ii) Expenses incurred for treatment of any of the following diseases:-
a. Asthma
b. Bronchitis
c. Chronic Nephritis and Nephritic Syndrome
d. Diarrhoea and all types of Dysenteries including gastroenteritis
e. Diabetes Mellitus and Insipidus
f. Epilepsy
g. Hypertension
h. Influenza, Cough and Cold
i. All Psychiatric or Psychosomatic Disorders
j. Pyrexia of unknown Origin for less than 10 days
k. Tonsillitis & Upper Respiratory Tract infection including Laryngitis and
pharangitis
l. Arthritis, Gout and Rheumatism
Liability of the company under this clause is restricted as stated in the
Schedule attached hereto

3.3 For AYUSH Treatment, hospitalization expenses are admissible only when
the treatment has been undergone in a Government Hospital or in any
Institute recognized by the Government and/or accredited by Quality
Council of India/National Accreditation Board on Health.
 Company's Liability for all claims admitted in respect of any/all insured
person/s during the period of insurance shall not exceed the Sum Insured
stated in the schedule.

4. EXCLUSIONS:
The company shall not be liable to make any payment under this policy in
respect of any expenses whatsoever incurred by any Insured Person in
connection with or in respect of:

4.1 Any Pre-existing condition(s) as defined in the policy, until 48 months of

continuous coverage of such insured person have elapsed since inception
of his/her first policy with the Company.

4.2 Any disease other than those stated in clause 4.3 below, contracted by
the Insured person during the first 30 days from the commencement date
of the policy. This exclusion shall not however, apply in case of the
Insured person having been covered under an Insurance scheme with our
Company for a continuous period of preceding 12 months without any
break.

During the first two years of the operation of the policy, the expenses on
treatment of diseases such as Cataract, Benign Prostatic Hyperthrophy,
Hysterectomy for Menorrhagia, or Fibromyoma, Hernia, Hydrocele,
Congenital internal disease, Fistula in anus, piles, Sinusitis and related
disorders, Gall Bladder Stone removal, Gout & Rheumatism, Calculus
Diseases are not payable. Internal Congenital Disease means anomaly
which is not visible and accessible parts of the body.

4.3 During the first four years of the operation of the policy, the expenses
related to treatment of Joint Replacement due to Degenerative Condition
and age-related Osteoarthritis & Osteoporosis are not payable.

If these diseases mentioned in Exclusion no.4.3 and 4.4 (other than

Congenital Internal Diseases) are pre-existing at the time of proposal they
will not be covered even during subsequent period of renewal subject to
the pre-existing disease exclusion clause. If the Insured is aware of the
existence of congenital internal disease before inception of the policy, the
same will be treated as pre-existing.

4.4 Injury/ disease directly or indirectly caused by or arising from or

attributable to War, invasion, Act of Foreign enemy, War like operations
(whether war be declared or not).
4.5 a. Circumcision unless necessary for treatment of a disease not excluded
hereunder or as may be necessitated due to an accident.
b. Vaccination or inoculation.
c. Change of life or cosmetic or aesthetic treatment of any description
such as correction of eyesight etc,
d. Plastic surgery other than as may be necessitated due to an accident or
as part of any illness.

4.6 Cost of spectacles and contact lenses, hearing aids.

4.7 Dental treatment or surgery of any kind unless necessitated by accident

and requiring hospitalization.

4.8 Convalescence, general debility; run-down condition or rest cure,

Obesity treatment and its complications including morbid obesity,
Congenital external disease/defects or anomalies, treatment relating to
all psychiatric and psychosomatic disorders, infertility, Sterility, Venereal
disease, intentional self injury and use of intoxication drugs / alcohol.

4.9 All expenses arising out of any condition directly or indirectly caused to
or associated with Human T-Cell Lymphotropic Virus Type III (HTLB - III)
or lymphadinopathy Associated Virus (LAV) or the Mutants Derivative or
Variation Deficiency Syndrome or any syndrome or condition of a similar
kind commonly referred to as AIDS.

4.10 Charges incurred at Hospital or Nursing Home primarily for diagnosis x-

ray or Laboratory examinations or other diagnostic studies not
consistent with or incidental to the diagnosis and treatment of positive
existence of presence of any ailment, sickness or injury, for which
confinement is required at a Hospital / Nursing Home.

4.11 Expenses on vitamins and tonics unless forming part of treatment for
injury or diseases as certified by the attending physician

4.12 Injury or Disease directly or indirectly caused by or contributed to by

nuclear weapon / materials.

4.13 Treatment arising from or traceable to pregnancy, childbirth, miscarriage,

abortion or complications of any of these including caesarean section,
except abdominal operation for extra uterine pregnancy (Ectopic
pregnancy), which is proved by submission of Ultra Sonographic report
 and Certification by Gynecologist that it is life threatening one if left
untreated.

4.14 Naturopathy Treatment, acupressure, acupuncture, magnetic therapies,

experimental and unproven treatments/ therapies. Treatment including
drug Experimental therapy, which is not based on established medical
practice in India, is treatment experimental or unproven.

4.15 External and or durable Medical / Non-medical equipment of any kind

used for diagnosis and or treatment including CPAP, CAPD, Infusion pump
etc. Ambulatory devices i.e., walker, crutches, Belts, Collars, Caps, Splints,
Slings, Braces, Stockings, elastocrepe bandages, external orthopedic pads,
sub cutaneous insulin pump, Diabetic foot wear, Glucometer /
Thermometer, alpha / water bed and similar related items etc., and also
any medical equipment, which is subsequently used at home etc.

4.16 Genetic disorders and Stem Cell implantation/surgery.

4.17 Change of treatment from one system of medicine to another unless

recommended by the consultant/hospital under which the treatment is
taken.

4.18 Treatment for Age related Macular Degeneration (ARMD), treatment

such as Rotational Field Quantum magnetic Resonance (RFQMR),
Enhanced External Counter Pulsation (EECP), etc.

4.19 All non-medical expenses including convenience items for personal

comfort such as charges for telephone, television, ayah, private
nursing/barber or beauty services, died charges, baby food, cosmetics,
tissue paper, diapers, sanitary pads, toiletry items and similar incidental
expenses.

4.20 Any kind of Service charges, Surcharges, Admission Fees/Registration

Charges, Luxury Tax and similar charges levied by the hospital

4.21 All non-Medical expenses. For detailed list of non-medical expenses,

please log on to our website www.uiic.co.in.

5. CONDITIONS:
5.1 Contract: the proposal form, declaration pre-acceptance health check-up
and the policy issued shall constitute the complete contract of insurance.
5.2 Every notice or communication regarding hospitalization or claim to be
given or made under this Policy shall be delivered in writing at the
address of the TPA office as shown in the Schedule. Other matters
relating to the policy may be communicated to the policy issuing office.

5.3 The premium payable under this Policy shall be paid in advance. No
receipt for Premium shall be valid except on the official form of the
company signed by a duly authorized official of the company. The due
payment of premium and the observance and fulfillment of the terms,
provisions, conditions and endorsements of this Policy by the Insured
Person in so far as they relate to anything to be done or complied with
by the Insured Person shall be a condition precedent to any liability of
the Company to make any payment under this Policy. No waiver of any
terms, provisions, conditions and endorsements of this policy shall be
valid unless made in writing and signed by an authorized official of the
Company.

5.4 Notice of Communication: Upon the happening of any event which may
give rise to a claim under this Policy notice with full particulars shall be
sent to the TPA named in the schedule immediately and in case of
emergency hospitalization within 24 hours from the time of
Hospitalization/Domiciliary Hospitalization

5.5 All supporting documents relating to the claim must be filed with TPA
within 15 days from the date of discharge from the hospital. In case of
post-hospitalization, treatment (limited to 60 days), all claim documents
should be submitted within 7 days after completion of such treatment.

Note: Waiver of this Condition may be considered in extreme cases of

hardship where it is proved to the satisfaction of the Company that
under the circumstances in which the insured was placed it was not
possible for him or any other person to give such notice or file claim
within the prescribed time-limit.

5.6 The Insured Person shall obtain and furnish the TPA with all original bills,
receipts and other documents upon which a claim is based and shall also
give the TPA/ Company such additional information and assistance as
the TPA/Company may require in dealing with the claim.
5.7 Any medical practitioner authorized by the TPA / Company shall be
allowed to examine the Insured Person in case of any alleged injury or
disease leading to Hospitalization if so required.
5.8 The Company shall not be liable to make any payment under this policy
in respect of any claim if such claim be in any manner fraudulent or
supported by any fraudulent means or device whether by the Insured
Person or by any other person acting on his behalf.

5.9 DISCLOSURE TO INFORMATION NORM

The Policy shall be void and all premium paid hereon shall be forfeited to
the Company, in the event of misrepresentation, mis-description or non-
disclosure of any material fact.

5.10 If at the time when any claim arises under this Policy, there is in
existence any other insurance (other than Cancer Insurance Policy in
collaboration with Indian Cancer Society), whether it be effected by or
on behalf of any Insured Person in respect of whom the claim may have
arisen covering the same loss, liability, compensation, costs or expenses,
the Company shall not be liable to pay or contribute more than its
rateable proportion of any loss, liability, compensation costs or
expenses. The benefits under this Policy shall be in excess of the
benefits available under Cancer Insurance Policy.

5.11 The Policy may be renewed by mutual consent and in such event the
renewal premium shall be paid to the Company on or before the date of
expiry of the Policy or of the subsequent renewal thereof. The Company
shall not be bound to give notice that such renewal premium is due,
provided however that if the insured shall apply for renewal and remit
the requisite premium before the expiry of this policy, renewal shall not
normally be refused, unless the Company has reasonable justification to
do so.

5.12 ENHANCEMENT OF SUM INSURED

The insured may seek enhancement of Sum Insured in writing at or
before payment of premium for renewal, which may be granted at the
discretion of the Company. However, notwithstanding enhancement,
for claims arising in respect of ailment, disease or injury contracted or
suffered during a preceding policy period, liability of the company shall
be only to the extent of the Sum Insured under the policy in force at the
time when it was contracted or suffered during the currency of such
renewed policy or any subsequent renewal thereof.
Any such request for enhancement must be accompanied by a
declaration that the insured or any other insured person in respect of
whom such enhancement is sought is not aware of any symptoms or
other indications that may give rise to a claim under the policy. The
 Company may require such insured person/s to undergo a Medical
examination to enable the company to take a decision on accepting the
request for enhancement in the Sum Insured.

5.13 Cancellation Clause:

The Company may at any time cancel this Policy by sending the Insured
15 days notice by registered letter at the insureds last known address
and in such event the Company shall refund to the Insured a pro-rata
premium for unexpired Period of Insurance. The Company shall,
however, remain liable for any claim, which arose prior to the date of
cancellation. The Insured may at any time cancel this Policy and in such
event the Company shall allow refund of premium at Company's short
period rate only (Table given here below) provided no claim has
occurred up to the date of cancellation.

PERIOD ON RISK RATE OF PREMIUM TO BE CHARGED

Up to one month 1/4 th of the annual rate
Up to three months 1/2 of the annual rate
th
Up to six months 3/4 of the annual rate
Exceeding six months Full annual rate.

5.14 If any dispute or difference shall arise as to the quantum to be paid

under the policy (liability being otherwise admitted) such difference shall
independently of all other questions be referred to the decision of a
sole arbitrator to be appointed in writing by the parties or if they cannot
agree upon a single arbitrator within 30 days of any party invoking
arbitration, the same shall be referred to a panel of three arbitrators,
comprising of two arbitrators, one to be appointed by each of the parties
to the dispute/difference and the third arbitrator to be appointed by
such two arbitrators and arbitration shall be conducted under and in
accordance with the provisions of the Arbitration and Conciliation Act,
1996.

It is clearly agreed and understood that no difference or dispute shall be

referable to arbitration as herein before provided, if the Company has
disputed or not accepted liability under or in respect of this Policy.

It is hereby expressly stipulated and declared that it shall be a condition

precedent to any right of action or suit upon this policy that award by
such arbitrator/arbitrators of the amount of the loss or damage shall be
first obtained.
5.15 If the TPA, as per terms and conditions of the policy or the Company
shall disclaim liability to the Insured for any claim hereunder and if the
Insured shall not within 12 calendar months from the date or receipt of
the notice of such disclaimer notify the TPA/ Company in writing that he
does not accept such disclaimer and intends to recover his claim from
the TPA/Company then the claim shall for all purposes be deemed to
have been abandoned and shall not thereafter be recoverable
hereunder.

5.16 All medical/surgical treatments under this policy shall have to be taken
in India and admissible claims thereof shall be payable in Indian
currency. Payment of claim shall be made through TPA to the
Hospital/Nursing Home or the Insured Person as the case may be.

5.17 Low Claim Ratio Discount (Bonus)

Low Claim Ratio Discount at the following scale will be allowed on the
total premium at renewal only depending upon the incurred claim ratio
for the entire group insured under the Group Mediclaim Insurance Policy
for the preceding 3 completed years excluding the year immediately
preceding the date of renewal where the Group Mediclaim Insurance
Policy has not been in force for 3 completed years, such shorter period
of completed years excluding the year immediately preceding the date
of renewal will be taken in to account
Incurred Claim ratio under the group policy Discount %
Not exceeding 60% 5
Not exceeding 50% 15
Not exceeding 40% 25
Not exceeding 30% 35
Not exceeding 25% 40

5.18 High Claims Ratio Loading (MALUS)

The total premium payable at renewal of the Group Policy will be loaded
at the following scale depending upon the incurred claims ratio for the
entire group insured under the Group Mediclaim Insurance Policy for the
preceding year (immediately preceding the date of renewal).
Incurred claims ratio under this group policy Loading
Between 70% and 100% 25 %
Between 101% and 125 % 55 %
Between 126 % and 150 % 90 %
Between 151 % and 175 % 120 %
Between 176 and 200 150%
Over 200 % Cover to be reviewed
 Note:
1. Low Claim Ratio Discount (Bonus) or High Claim Ratio loading (Malus)
will be applicable to the Premium at renewal of the Policy depending
on the incurred claims Ratio for the entire Group Insured.

2. Incurred claim would mean claims paid plus claims outstanding in

respect of entire group insured under the policy during relevant
period.

The insured shall throughout the period of insurance keep and maintain a
proper record of register containing the names of all the insured persons
and other relevant details as are normally kept in any institution/
Organisation. The insured shall declare to the company any additions in the
number of insured persons as and when arising during the period of
insurance and shall pay the additional premium as agreed.

It is hereby agreed and understood that, that this insurance being a Group
Policy availed by the Insured covering Members, the benefit thereof would
not be available to Members who cease to be part of the group for any
reason whatsoever.

Such members may obtain further individual insurance directly from the
Company and any claims shall be governed by the terms thereof.

6 MATERNITY EXPENSES BENEFIT EXTENSION :( Wherever applicable)

This is an optional cover, which can be obtained on payment of 10% of total

basic premium for all the Insured Persons under the Policy.

Option for Maternity Benefits has to be exercised at the inception of the

Policy period and no refund is allowable in case of Insured's cancellation of
this option during currency of the policy.

The hospitalization expenses in respect of the new born child can be

covered within the Mothers Maternity expenses. The maximum benefit
allowable under this clause will be up to Rs. 50,000/- or the sum insured
opted by the group whichever is lower.

Special conditions applicable to Maternity expenses Benefit Extension:

1. These Benefits are admissible only if the expenses are incurred in

Hospital / Nursing Home as in-patients in India
 2. A waiting period of 9 months is applicable for payment of any
claim relating to normal delivery or caesarean section or
abdominal operation for extra uterine pregnancy. The waiting
period may be relaxed only in case of delivery, miscarriage or
abortion induced by accident or other medical emergency.

3. Claim in respect of delivery for only first two children and / or

operations associated therewith will be considered in respect of
any one Insured Person covered under the policy or any renewal
thereof. Those Insured Persons who are already having two or
more living children will not be eligible for this benefit.

4. Expenses incurred in connection with voluntary medical

termination of pregnancy during the first 12 weeks from the date
of conception are not covered.

5. Pre-natal and postnatal expenses are not covered unless admitted

in Hospital / Nursing Home and treatment is taken there.

Note: When group policy is extended to include Maternity Expenses

Benefit, the exclusion No.4.14 of the policy stands deleted.

10 IMPORTANT NOTICE
The Company may revise any of the terms, conditions and exceptions of
this insurance including the premium payable on renewal in accordance
with the guidelines/rules framed by the Insurance Regulatory and
Development Authority (IRDA). We shall notify you of such changes at least
three months before the revision are to take effect.

The Company may also withdraw the insurance as offered hereunder after
following the due process as laid down by the IRDA and we shall offer to
cover you under such revised/new covers for which we shall have obtained
from the Authority at such terms, conditions, exceptions and premium that
the IRDA may have approved.

*****
 FORMING PART OF
HEALTH INSURANCE POLICY GROUP
SPECIAL CONDITIONS APPLICABLE TO CO-BRANDED

INDIAN BANK
AROGYA RAKSHA GROUP HEALTH INSURANCE POLICY
Some of the conditions are relaxed from our normal policy for Indian Bank
accountholders. The special conditions for Arogya Raksha are compared with
the normal mediclaim Group policy, and the same is given below:

AGE LIMT: 3 MONTHS TO 65 YEARS & RENEWAL AGE is unlimited.

PLANS & SUM INSURED:

Plan A: Accountholder + Spouse + Two Dependent Children (1+3) - Age Group

up to 35 years
Plan B: Accountholder + Spouse + Two Dependent Children (1+3) - Age Group
above 35 years
Plan C: Accountholder Spouse + Two Dependent Children + Dependent Parents
(1+5) Age Group above 35 years

DEPENDENT CHILDREN AGE:

For daughters, cover is available under this scheme until the girl gets married
or gets employment whichever occurs earlier without age restriction.

For the dependent male children cover is restricted up to the age of 25 years or
till he gets employment or his marriage whichever is earlier.

Without paying additional premium the new member i.e new born child /newly
married spouse can be covered under this scheme subject to maximum
number of members in the family not exceeding 6 members in total. The
benefits offered under the policy for the new entrant(s) will be subject to thirty
days / one year, pre existing and other exclusions of the policy.

1.2
A. Room, Boarding and Nursing Expenses as provided by the Hospital /
Nursing Home up to 1.5 % of Sum Insured per day. This also includes
Nursing Care, RMO charges, IV Fluids / Blood Transfusion/Injection
administration charges and the like.
 B. If admitted in IC Unit, the per day room rent limit will be 3% of the sum
insured.
C. Surgeon, Anesthetist, Medical Practitioner, Consultants, Specialists Fees
D. Anaesthetist, Blood, Oxygen, Operation Theatre Charges, surgical
appliances, Medicines & Drugs, Diagnostic Materials and X-ray, Dialysis,
Chemotherapy, Radiotherapy, Artificial Limbs, cost of prosthetic devices
implanted during surgical procedure like Pacemaker, relevant laboratory
diagnostic tests, etc & similar expenses.
E. All Hospitalisation Expenses (excluding cost of organ, if any) incurred for
donor in respect of Organ transplant.

1.2.1 Expenses in respect of the following specified illnesses will be restricted

as detailed below:

Hospitalization Benefits LIMITS FOR EACH HOSPITALISATION

a. Cataract a. 10% of SI subject to maximum of Rs.25,000/-
b. Hernia b. 15% of the SI subject to maximum of Rs.30,000/-
c. Hysterectomy c. 20% of the SI subject to maximum of Rs.50,000/-
d. All major surgery as d. Actual expenses incurred or 80% of the SI whichever
specified by doctor is less
Pre & Post - Actual expenses subject to maximum of 10% of Sum
Hospitalization in respect Insured.
of any illness

(N.B: Companys Liability in respect of all claims admitted during the period of
insurance shall not exceed the Sum Insured as mentioned in the schedule)

In respect of persons above 65 years, 10% deductible will be applied on all

admissible claims.

Expenses on major illness To be settled with a co- pay on 80:20 basis. The co
charged as a total package pay of 10% will be applicable on the admissible
claim amount

2.11 DOMICILIARY HOSPITALIZATION:

There is no Domiciliary Hospitalization cover available under Arogya Raksha
Policy

2.29 OPD TREATMENT:

There is no OPD treatment cover available under Arogya Raksha Policy
EXCLUSIONS
4.2 In this clause, waiting period of two years shall be read as one year in case
of Arogya Raksha
4.3 This clause is not applicable for Arogya Raksha.
4.13 This clause does not apply for Arogya Raksha.

5.12 ENHANCEMENT OF SUM INSURED:

Subject to this clause, in Arogya Raksha, during renewal, the client may
increase the sum insured to the next slab only.

6. MATERNITY EXPENSES BENEFIT EXTENSION:

Under Arogya Raksha, there is no additional premium for Maternity cover and
may be read in place of the clauses 6 as given below:
i) Maternity Expenses Benefits: Means treatment taken in
hospital/nursing home arising from or traceable to pregnancy childbirth
including normal caesarean section. Waiting period is 9 months and the
reimbursement / cashless facility is available for first two children.
Those Insured Persons who are already having two or more living
children will not be eligible for this benefit.
ii) Pre-natal and postnatal expenses are not covered unless admitted in
Hospital / Nursing Home and treatment is taken there.
iii) Baby care means, expenses relating to treatment given to the new born
child in the hospital as an inpatient for a maximum period of 90 days
from the date of its birth. The reimbursement of Maternity and baby
care will be limited to the actual expenses subject to a maximum of 5%
of sum insured opted in the mediclaim section. After 90 days from the
date of birth, the baby will have to be covered under policy on payment
of additional premium.
In addition to the above, the following additional benefits are also available for
Arogya Raksha Policy which is to be added as part of the special conditions
forming part of the policy:
a) Reasonable ambulance charges:
Reasonable ambulance charges include charges incurred for emergency
transport of the patient from the residence/place of accident/illness to
the hospital where treatment is taken. It also includes ambulance charges
for transport of the patient by the hospital. Where patient is being taken
to another hospital for treatment/ diagnostic tests etc. but subject to a
maximum of RS.1000/- per policy period. The relevant bills for such
ambulance charges will have to be submitted by the insured. The
ambulance charge is part of the total sum insured under the Mediclaim
policy.
 b) Hospital cash:
Up to Rs.1,000/- to parents in case of hospitalization of children up to 12
years of age:
Cash allowance of RS.100/- per day subject to a maximum of RS.1000/-
will be given to the parents/guardians of children up to the age of 12 who
are hospitalized and there is a valid claim under the policy. Hospital cash
forms a part of the total sum insured under the policy.

c) Cost of health check up :

The insured shall be entitled for reimbursement of the cost of medical
checkup once at the end of every three underwriting years provided
there are no claims reported during the block. The cost so reimbursable
shall not exceed the amount equal to 1 % of the amount of average sum
insured during the block of four claim free underwriting years of the
policy issued by United India Insurance Co. Ltd..
IMPORTANT: The health check up provision is applicable only in respect of
continuous insurance without break.

d) Funeral expenses: RS.1000/- :

In case the insured or his family members have died following
hospitalization due to an illness/accident and their eyes have been
donated to a recognized institution. Funeral expenses of RS.1 000/- will
be paid under the policy on production of the original certificate from the
said institution. This is subject to there being a valid claim under the
mediclaim policy. This amount will be reimbursed over and above the
sum insured opted.

f) Reimbursement of expenses - NEPAL & BHUTAN:

Reimbursement in Indian Rupees of emergency hospitalization expenses
for treatment at Nepal or Bhutan while insured is away at these places
either on holiday or business purposes. Cashless facility is not offered
under this extension.

SALIENT FEATURES OF PERSONAL ACCIDENT (DEATH) INSURANCE:

The Policy provides that, if at any time during the currency of this policy
the insured and his/her family members shall sustain any bodily injury
resulting sole and directly from accident caused by external violent and
visible means resulting in death, then the company shall pay to the
insured of his legal personal representative(s) as the case may be.
SUM INSURED UNDER PERSONAL ACCIDENT COVER:

Account Holder: 100% of mediclaim Sum Insured (SI), Spouse: 50% of

mediclaim SI, Children: 25% each, Nomination facility available.
Total claim settlement will not exceed the eligible / opted sum insured.

The Policy excludes death due to:

1. Intentional Self Injury / Suicide / Attempted Suicide

2. Whilst under influence of intoxicating liquor or drugs
3. Whilst engaged in Aviation or Ballooning
4. Due to Veneral diseases or Insanity
5. Due to Insured committing any breach of law with Criminal intent
6. From Service in the armed forces
7. Directly or indirectly from child-birth or pregnancy